Archived: Chelwood Dental Practice

Updated 30 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection was led by a CQC inspector who was supported by a specialist dental adviser. The inspection was supported by a second CQC inspector.

We informed local NHS England area team and Healthwatch that we were inspecting the practice. We did not receive any information of concern from them.

During the inspection we recieved feedback from 25 patients. We also spoke with members of the dental team including dentists, dental nurses and the receptionist. To assess the quality of care provided we looked at practice policies and protocols and other records relating to the management of the service. We also reviewed other relevant information the practice provided before and during the day of inspection.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 30 November 2016

We carried out an announced comprehensive inspection on 5 October 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations

Background

Chelwood Dental Practice is situated in Roundhay, which is a district of Leeds, West Yorkshire. It offers mainly NHS dental treatment to patients of all ages. They also provide private treatment including cosmetic dentistry. The services include preventative advice and treatment and routine restorative dental care.

The practice has two surgeries, a decontamination room, a waiting area and a reception area. All of the facilities are on the ground floor of the premises along with accessible toilet facilities.

There are three dentists, four dental nurses (one of whom has recently qualified) and one receptionist. One of the dental nurses is also the practice manager.

The opening hours are 8am to 1pm every weekday morning, 2pm to 7pm Monday to Wednesday and 2pm to 5.30pm on Thursdays and Fridays. When the practice is closed, calls are transferred to the NHS 111 service.

The principal dentist is registered with the Care Quality Commission (CQC) as an individual. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

During the inspection we received feedback from 25 patients. The patients were positive about the care and treatment they received at the practice. Comments included that staff were friendly and efficient. Several patients commented that the practice was clean. They also commented that they were able to get appointments when they needed them, including same day appointments and staff spent time explaining treatment options.

Our key findings were:

• The practice had been renovated to a high standard and was visibly clean and uncluttered.
• The practice had systems in place to assess and manage risks to patients and staff including health and safety and the management of medical emergencies.
• Staff were qualified and had received training appropriate to their roles.
• Patients were involved in making decisions about their treatment and were given clear explanations about their proposed treatment including costs, benefits and risks.
• Dental care records showed that treatment was planned in line with current best practice guidelines.
• Oral health advice and treatment were provided in-line with the ‘Delivering Better Oral Health’ toolkit (DBOH).
• We observed that patients were treated with kindness and respect by staff.
• There was a warm and welcoming feel to the practice.
• Staff ensured there was sufficient time to explain fully the care and treatment they were providing in a way patients understood.
• The practice had a complaints system in place and there was an openness and transparency in how these were dealt with.
• Patients were able to make routine and emergency appointments when needed.
• The governance systems were effective.
• There were clearly defined leadership roles within the practice and staff told us that they felt supported, appreciated and comfortable to raise concerns or make suggestions.
• There was appropriate equipment for staff to undertake their duties, and equipment was well maintained.

There were areas where the provider could make improvements and should:

• Review stocks of medicines and the system for dispensing and identifying and disposing of out-of-date stock.
• Review it’s responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
• Review the practice’s arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).